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MINNESOTA JOINT UNDERWRITING ASSOCIATION <br />PIONEER P.O. BOX 1760 <br />ST. PAUL, MN 55101 <br />1 -800- 552 -0013 OR (612) 222 -0484 <br />APPLICATION FOR LIQUOR LIABILITY COVERAGE <br />Coverage will not be bound if the correct premium payment, written <br />rejection, current • license and required documentation of liquor <br />receipts are not attached. Coverage cannot be bound prior to <br />12:01 a.m. the day following receipt of the above by the <br />Administrator. <br />Legal Name of Applicant <br />21T7kE CAwpdA REcRre,Troit) ASScc7.O71.r <br />Trade Name <br />Mailing Address Ste 9. 47774E CAwAAA Rb. hITTIE CA144M S'SIP <br />_Individual Partnership _Corporation Dion- Profit Other <br />If Applicant is Individual: <br />Applicant Name Spouse Name <br />If Applicant is a Partnership of Corporation: <br />Name of Each Partner or Owner Percentage of Ownership <br />Operating Location(s) - List all Locations: <br />1. VA/6 12774E Cr9evA6A fib 2. <br />Classification <br />Primary Nature of Business: <br />Check all applicable. <br />1. Restaurant 2. '. Club. 3.. Bar <br />4. !_Bowling alley 5. On /Off Sales <br />6. Off Sale Only 7. VSpecial Event pg�� <br />Total Gross Receipts of Entire Establishment '" .2 3 O O <br />Gross Receipts from Liquor Sales Included Above <br />Seating Capacity /A.0 Total Bar Only <br />License in Effect? Yes No P6 N D?n> 6 <br />Licensing Authority A27Tik CANA44 <br />Address tis £. Lin Lr tAN,o AA _to <br />License Number <br />Effective Date /j.?�f 9 y Expiration Date it? 8/9f <br />License Ever Revok d /Susp nded? _Yes t., No If yes, te <br />If yes, explain <br />Page 32 <br />